New Psychologist Setup Form Psychologist's Information Below you will need to upload 1.) your License AND 2.) your Professional Liability Insurance. Name* First Last Your Email* Your Phone*Your Date of Birth* Your Social Security Number* Your Gender* Male Female Your Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Individual NPI # Your Credentials (abbreviations)* Your Taxonomy Code Do you have a CAQH account set up yet?* Yes No If yes, please list username and password:Insurance Companies in network withPlease list the name of all the insurance companies that you were in network with at your last job.What is the day you started working/will start at this new clinic?*(First date treating patients) MM slash DD slash YYYY Upload your 1.) License AND 2.) Professional Liability Insurance* Drop files here or Select files Max. file size: 256 MB. NameThis field is for validation purposes and should be left unchanged.